Negative Urine Cultures: Less is Better When it Comes to Antibiotics

DrLydiaFurman, MD, Assistant Editor, Pediatrics

In a recently released issue of
Pediatrics, an excellent quality improvement (QI) study by Dr. Dipsnwita Saha (
10.1542/peds.2016-2103) and colleagues describes initiation of a process to discontinue antibiotics when
a urine culture is negative for patients receiving care in their Pediatric Urgent
Care Network. Typically one thinks of a quality improvement project as adding an intervention
or intervention bundle, so that all eligible patients receive a treatment; in this
interesting study eligible patients benefitted from
not receiving a treatment, i.e. unnecessary antibiotics for a negative urine culture.
The authors’ focus on follow up, rather than on decreasing initial prescribing, is
supported by data documenting that about 50% of urinary tract infections are missed
in primary care settings.
1,2 Treating fewer children at initial presentation would thus be a QI strategy that
awaits improved methods of urinary tract infection (UTI) identification.

The study included use of PDSA (plan,do,study,act) cycles and a standardized protocol
with 5 steps from initial review of urine culture results by a nurse through clinician
notification, assessment and decision making, to nurse notification to the patient,
and then clinician documentation of the antibiotic discontinuation in the electronic
medical record (EMR). Interestingly the most challenging step was the last, of clinician
documentation, i.e. medication reconciliation, in the EMR. Since most inpatient and
ambulatory EMRs are shared documents with multiple clinicians able to access and revise,
in our own anecdotal experience this may lead to a lack of ownership by individual
clinicians or to frustration with attempts to “clean up” the medical record. Whether
this or simply time and knowledge were the barriers to clinician EMR documentation
is not known, but the authors used email reminders with screen shots and in-person
meetings to reinforce the medication reconciliation needed.

As the authors note, 2-4 days of antibiotic can successfully treat a UTI in children
3 months of age or older with lower tract infection only, so stopping antibiotics
for patients who are prescribed a 7-10 day course is critical stewardship.3,4 Their initiative increased local attention to several issues related to prescribing
for UTIs, and several new QI initiatives were started at their institution following
this published study, including one to “optimize antibiotic choice and duration.”
I will look forward to reading the results of that project!